Case 3, presented by Beth E. Shubin Stein, MD, Sabrina M. Strickland, MD and Jacqueline Munch, MD describes a 36-year-old Korean woman who presented with a history of longstanding bilateral knee pain with recurrent multidirectional left patellar instability. Twenty years prior, while living in Korea, she underwent bilateral Hauser procedures, along with medial imbrication and lateral release. She had become so incapacitated by pain and instability that she had stopped participating in any activities other than simple activities of daily living. On physical examination, she had well-healed scars, but marked quadriceps atrophy and hypertrophy of the gastrocnemius bilaterally. She could not perform a squat, for fear that her left patella would dislocate. She had positive patellar grind tests bilaterally, as well as tenderness to palpation of the lateral trochleae and patellae. Both patellae demonstrated fixed lateral tilt. She was apprehensive to lateral patellar translation on the left, and in fact demonstrated lateral dislocation in the flexed position, then relocation with progression from flexion to extension of the knee. In extension, her patella tracked, and could be subluxed, medially. On radiographic examination, there were hypoplastic trochleae, with significant bilateral patellofemoral arthritis. The left side demonstrated lateral tilt and subluxation of the patella relative to the trochlea. The lateral radiographs confirmed patella baja. Left knee MRI demonstrated very mild medial compartment wear but otherwise an intact tibiofemoral joint space. There was full thickness chondral loss on the patella and the lateral trochlea (Figure 3). At age 40, the patient underwent left patellofemoral arthroplasty with soft tissue proximal re-alignment (Figure 4). Once her patella and trochlea had been resurfaced, and the lateral portion of her quadriceps was advanced, the patellofemoral joint tracked well. Two years after her surgery, she has maintained patellofemoral stability, is pain free, and has resumed playing golf.